Therapeutics

Review: Pharmacist care improves therapeutic and safety outcomes in older adults

Lee JK, Slack MK, Martin J, Ehrman C, Chisholm-Burns M. Geriatric patient care by US pharmacists in healthcare teams: systematic review and meta-analyses. J Am Geriatr Soc. 2013;61:1119-27.

Clinical impact ratings: F ★★★★★✩✩ G ★★★★★★✩ Question In older adults, what is the efficacy of pharmacist care?

Review scope Included studies compared patient-level US pharmacist interventions intended to improve therapeutic outcomes, reduce hospitalizations, improve safety, or increase medication adherence with alternative care on objective, patient-related health outcomes in adults ≥ 65 years of age. Outcomes included therapeutic, safety, and hospitalization categories.

Review methods MEDLINE, ABI/INFORM, Health Business Fulltext Elite, Academic Search Complete, International Pharmaceutical Abstracts, PsycINFO, Cochrane Database of Systematic Reviews, ClinicalTrials.gov, and reference lists of review articles and metaanalyses (all 2009 to Jul 2012) were searched for randomized controlled trials (RCTs), comparative cohort studies, pre–post studies, and before-and-after studies. {Eligible studies published through Jan 2009 were extracted from a database compiled for a systematic review.}* Clinical drug trials, case studies, systematic reviews, meta-analyses, nonresearch articles, and studies done outside of the USA were excluded. 20 studies (n = 9679, mean age 67 to 86 y, 17 to 99.5% men) met the inclusion criteria. Sample size ranged from 36 to 4218. 6 studies were RCTs, 4 were prospective cohorts, 5 were pre–post studies, 2 were beforeand-after studies, and 3 were retrospective cohort studies. The most common practice settings were ambulatory clinics (6 studies) and inpatient settings (5 studies). Pharmacists provided technical interventions (addressing medication regimen possibly through therapeutic change or interchange, simplifying dose regimen or schedule, and use of tools) in 18 studies.

Main results Meta-analysis showed that pharmacist care favorably affects therapeutic, safety, and hospitalization outcomes (Table). Between-study variability for therapeutic (I2 = 89%) and hospitalization (I2 = 74%) outcomes was substantial.

Conclusion Pharmacist care improves therapeutic, safety, and hospitalization outcomes in older adults in the USA. Pharmacist care vs control in adults ≥ 65 years of age† Outcomes

Number of trials (n)

Standardized mean difference‡ (95% CI)

Therapeutic Safety

8 (2376)

−0.81 (−0.94 to −0.67)

10 (5732)

−0.33 (−0.44 to −0.22)

6 (2406)

−0.33 (−0.44 to −0.23)

Hospitalization

*Chisholm-Burns MA, Kim Lee J, Spivey CA, et al. US pharmacists’ effect as team members on patient care: Systematic review and meta-analyses. Med Care 2010;48:923-933.

Source of funding: No external funding. For correspondence: Dr. J.K. Lee, University of Arizona, Tucson, AZ, USA. E-mail [email protected]

Commentary Adverse drug events are a serious phenomenon complicating the care of older adults. A recent study estimated that 100 000 emergent hospitalizations of patients ≥ 65 years of age are attributable to adverse drug events in the USA every year (1). Most of these admissions and readmissions are due to use of antithrombotic and antidiabetic agents (1), classes of medication that require special surveillance in older adults. The systematic review and meta-analyses by Lee and colleagues examined health outcomes when interdisciplinary teams included a pharmacist with a more direct clinical role than usual in the management of drug regimens in adults ≥ 65 years of age. The review was imperfect, as acknowledged by the authors. Only 6 of the 20 included studies were RCTs. The roles of pharmacists, venues of care, and outcomes in the interventions assessed by each study were very heterogeneous. In most instances, surrogate markers were used. Nevertheless, pharmacist care improved therapeutic, hospitalization, adherence, and safety outcomes. Most of the included studies were published before 2010, and much has changed in the health care arena since then. Medicare prescription drug benefits have been enhanced, especially for patients needing high-cost medications. Mandates for electronic prescribing and rapid development of “smart” order writing in electronic medical records should make prescribing safer. Simultaneously, however, most primary care physicians are under unprecedented documentation constraints such that counseling time is in short supply. As we move toward a health care system that rewards value and population health, we should welcome the addition of pharmacists working collaboratively in interdisciplinary teams to enhance the care of older adults. William J. Hall, MD, MACP University of Rochester School of Medicine Rochester, New York, USA Reference 1. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365:2002-12.

†CI defined in Glossary. ‡Negative difference favors pharmacist care.

JC6

© 2013 American College of Physicians

19 November 2013 | ACP Journal Club | Volume 159 • Number 10

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ACP Journal Club. Review: pharmacist care improves therapeutic and safety outcomes in older adults.

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